Personality & Behavioural Disorders Unit NSW Department of Corrective Services PBDU@dcs.nsw.gov.au

1. Assisting NSW correctional centres in their management & treatment of offenders with a severe personality disorder and challenging behaviours Personality & Behavioural Disorders Unit NSW Department of Corrective Services PBDU@dcs.nsw.gov.au

2. Outline • Overview of PBDU and NSW corrective services • Prevalence and management of PD in corrections • Team model and composition • Referral demographics • Clinical procedures: • Eligibility • Referral and selection • Assessment/Intervention • Staff training and consultancy • Evaluation protocol- key measures

3. Personality & Behavioural Disorders Unit Recently established, multidisciplinary team providing expertise to correctional centres managing offenders with severe personality and behavioural disorders

4. NSW Corrective Services • Manage offenders in a safe, secure & humane environment and reduce the risk of re-offending • 31 correctional centres: • 8 maximum security • 13 medium security • 10 minimum security • Approx 10,000 offenders in custody • 66 Community Offender Services offices • Approx 18,000 offenders in community

5. Prevalence of PD in Corrections Female (NSW) • 38-57%: ‘any personality disorder’ • 13-31%: Borderline • 13-32%: Impulsive Male (NSW) • 36-40%: ‘any personality disorder’ • 13-19%: Borderline • 19-21%: Impulsive (IPDE; Butler & Allnut, 2003) Overseas/US data • 30-60% male offenders diagnosed with BPD alone • Up 70% diagnosed with ASPD

6. Severe PD in Corrections • Higher risk of accidental death & suicide • High security, restricted environments • segregated custody; safe/camera cell placement • Limited time out of cell/access to services/interaction with peers • Disproportionate operational costs (IAT; medical escorts; use of force; ripple effect)

7. Severe PD in Corrections • Source of occupational stress (Duff, 2006) • Reduced job satisfaction • Absenteeism • Staff turnover • Prevents addressing offending behaviour, many at high risk (Howells, 2007) • Institutional practices/staff behaviour inadvertently reinforce problem behaviour (Pannel et al 2003) • Staff ‘splitting’: negative team ‘dynamics’

8. Team Composition Multidisciplinary • Team Leader • Clinical and Forensic psychologists • Behaviour Management Specialist • Senior Assistant Superintendent (senior correctional officer) • ? MH Nurse

9. Model of Service Provision • Mobile ‘behavioural intervention team’ • Work collaboratively with correctional staff provide: • Functional analysis of problem behaviour • Develop & evaluate behavioural and other interventions • Staff consultancy and training

10. Background and Philosophy • Positive model of change: ‘positive behavioural programming’ • Increase alternative, adaptive behaviours as well as reduce problem behaviour • Safe progression of patients to less restrictive environment • Opportunity to address their broader mental health and criminogenic needs • Early first-stage treatment targets (Linehan, 1993)

11. Roles and Responsibilities • Correctional centre management are responsible for making appropriate resources and staff available for the implementation of the agreed behavioural interventions • Once the behavioural intervention has been implemented and consistently maintained, the PBDU withdraws and thereafter provides a monitoring and supportive role to sustain its integrity and efficacy

12. Eligibility Defined operationally: • Threatened or actual self harm behaviour • Threatened or actual harm to others • Other behaviours which create a high demand on centre services and/or that affect the good management of the centre • Previous attempts to address the challenging behaviour by the centre have not been successful and a higher level or intensive behavioural intervention is required • Associated with a severe personality and/or other psychological disorder

13. Referral and Selection Process • referrals need to be endorsed by either the General Manager or Manager of Security of the centre • Priority will based upon the: • Level of risk • Persistence/chronicity or escalation/deterioration • Overall disruption caused to the management of the centre • Need for classification progress • Date of release

14. Demographics • Age: 16-40 years • Gender: 27% female; 73% male • ATSI: 27% • Unsentenced 27%; sentenced 73% • NGMI: 5% • Most convicted of serious offence e.g. murder, aggravated assault, malicious wounding

15. Demographics • Diagnosis: 55% BPD/traits; > 70% ASPD • Co-morbidity: AOD; substance induced psychotic disorders; developmental disability; other major mental illness • Extreme developmental or psychosocial adversity • Most prescribed psychiatric medication e.g. antidepressant/anticonvulsants; antipsychotic, anxiolytics

16. Programme Strategies • Engagement and Assessment • Intervention and evaluation • Through-care and maintenance • Staff training and consultancy

17. Engagement and Assessment • Comprehensive, multimodal assessment: • Review of existing data, file and collateral information • Discussion with relevant staff • Clinical & psychometric assessment (where appropriate) • Behavioural observation

18. Functional Analysis of Challenging Behaviour • Strong evidence for functional approach to problem behaviour • Developmental disorders (Didden, et al, 1997 • DBT for problem behaviours associated with BPD (Linehan, 1993) • More recently inpatient/incarcerated severe PD (Daffern, 2007) • Problem behaviour served a purpose in past but now no longer adaptive • Often serves multiple functions: resistant to change of extinction

19. Functional Analysis of Challenging Behaviour • Data is collected on entire sequence of problem behaviour including antecedents and consequences • Elicit underlying function/purpose of behaviour • Use structured guide to FA (ACF, Daffern 2006) • Reduce time required to complete traditional idiographic assessment • Simplifies decision-making process by identifying the most common functions of aggression • Use sequential hypothesis testing to evaluate interventions

20. Common Functions- Aggression(Daffern et al, 2008) • Demand avoidance • To force compliance • To express anger • To reduce tension • To obtain tangibles • To reduce social distance (attention seeking) • To enhance status or social approval • Compliance with instruction • To observe suffering • Seeking sensation • Sexual gratification

21. Common Functions- Self-harm(Klonsky, 2007) • Affect-regulation • Anti-dissociation • Anti-suicide • Interpersonal influence • Interpersonal boundaries • Self-punishment • Sensation seeking

22. Functional Analysis of Challenging Behaviour • In practice, FA is difficult to implement • Reliant on direct contact staff: • Recording data as behaviour occurs • Providing reliable retrospective report in interview • Hence validity of many FA s are limited by missing or distorted data • Establish effective data collection procedures in host centres

23. Multi-Modal Data Collection • Direct behavioural observation • Direct (unobtrusive), live video, pre-recorded video • Semi-structured clinical interview with staff • Custodial, JH, OS&P • Semi-structured clinical interview with offender (if appropriate) • File/incident report review • Running sheets, MNF, officer reports, RIT forms, IRM, JH file etc

24. Integrated Behaviour Management Plans • Collaborate with correctional staff to develop individualised behavioural interventions • Behavioural interventions modify either or both: • antecedent ‘trigger’ (i.e. environmental changes), or the • consequences that ‘reinforce’ the behaviour (e.g. staff behaviour) • Operationally feasible and sustainable • Team work and consistency from single plan that integrates variety of stakeholders

25. Integrated Behaviour Management Plans • Skills-based training to assist patient to develop alternative, pro-social behaviours • Behavioural progress to be matched by proportionate, incremental progression or security reduction within the centre • Reductions in security/increased freedom may function as • ‘positive reinforcement’ for behavioural changes • ‘graded exposure’ to improve self-management and self-regulation skills

26. Integrated Behaviour Management Plans • Progression may include • Placement/security management within the centre • Socialization/integration with other patients • Participation in general wing activities e.g. education, specialised exercise etc. • Increased contact with non custodial staff e.g. OS&P; JH • Progression to a ‘step-down’ or mainstream unit with support

27. Additional Interventions(work in progress) • PBDU recently organized training of 20 correctional psychologists in DBT (Hunter Mental Health) • Currently working with these psychologists and other specialist units in the implementation of a DBT informed programme within DCS

28. Throughcare and Maintenance • Phased withdrawal of PBDU and progression to less restrictive management • Assist in adapting behaviour interventions to other settings • Ensuring generalization of behaviours • Liaison with external services e.g. DADHC etc . • Follow up consultancy, booster training

29. Staff Training and Consultancy • Strong relationship between staff attitudes (towards PD and CB) and quality of care provided (Duff et al, 2006): • Rigid staff attitudes associated with staff pessimism, provision of less help and increased negative emotions • Increased behavioural knowledge reduced staff reported depression and anger immediately following an incident • Thus behavioural interventions that do not address staff attitudes and attributions of patient behaviour may be ineffective

30. Staff Training and Consultancy • PBDU provides a modularized, flexible training format to meet needs of correctional centres • Foundation training for all correctional centre staff • Target training for those who manage challenging behaviours (e.g. regular staff within relevant units) • Special issues: ‘Addressing staff splitting’

31. Evaluation protocol(work in progress) • Difficulties conducting RCTs in forensic mental health setting (Davis et al, 2007) • Case flow/total no. of patients may be too small • Organizational and ethical difficulties with random allocation • Heterogeneity of population • Heterogeneity of interventions and treatments • Participants not blind to experimental condition • Long term nature of treatment

32. Evaluation protocol(work in progress) • Single-case design may be a more suitable model • Under-utilized but has long history in clinical practice • Emerging journals and guidelines (e.g. APA) • Causal inference can be made about interventions if/when: • Clear measurement rules and analytic procedures • Clear identification of components of treatment • Using and analysing baselines appropriately

33. Key measures • Personality Diagnostic Questionnaire- 4 • Daily Risk Assessment (adapted Ogloff et al 2006) • Offender Behaviour Scale (adapted Silver et al 1987)- both incident & time period • Assessment & Classification of Function (Daffern, 2008) • Offender Service-Use Scale • Clinical measures: TBA

34. Personality Diagnostic Questionnaire- 4 • Screens for DSM IV Personality Disorder diagnoses • 110 item • Self administered • 20-30 minutes to administer • Diagnoses need to confirmed by clinical interview • Acceptable overall accuracy in prison populations (Davison et al, 2001) • Previous version effective screen for BPD in clinical and non-clinical populations (Dubro et al, 1988; Hyler, et al, 1989)

35. Daily Risk Assessment (DASA, Ogloff et al 2006) • 7 item scale • Irritability • Verbal threats • Sensitive to provocation • Easily angered requests denied • Unwilling to follow directions • Impulsivity • Negative attitudes • One of few scales that measure ST/24 hour risk

36. Daily Risk Assessment (DASA, Ogloff et al 2006) • Includes items most strongly associated with inpatient violence • ‘Dynamic factors’ that are amenable to change • Hence contribute to treatment planning • Only validated on a forensic psychiatric population

37. Offender Behaviour Scale(adapted OAS, Silver & Yudosky 1987) • Both Incident Specific and Time Period • 5 categories • Verbal Aggression • Physical Aggression- Objects • Physical Aggression- Self • Physical Aggression- Others • Inappropriate Sexual Behaviour

38. Offender Behaviour Scale(adapted OAS, Silver & Yudosky 1987) • Measures severity & frequency • Validated on range of different populations • Good psychometric properties when used by raters with minimal training • Group rating better than individual

39. Assessment & Classification of Function(Daffern et al, 2006) • Structured scheme to guide functional analysis • Reduce time required to complete traditional idiographic assessment • Simplifies decision-making process by identifying the most common functions of aggression

40. Assessment & Classification of Function(Daffern et al, 2006) • Demand avoidance • To force compliance • To express anger • To reduce tension • To obtain tangibles • To reduce social distance (attention seeking) • To enhance status or social approval • Compliance with instruction • To observe suffering • Seeking sensation • Sexual gratification

41. Assessment & Classification of Function(Daffern et al, 2006) • Pilot reliability studies indicate that acceptable levels of reliability • intra-class correlation for single rater is .64 • Intra-class correction for rater averaged .94 • Results from Dangerous & Severe Personality Disorder Units (UK) (Daffern, et al 2006) • Highlight the importance of affective states (Anger expression & Release tension) even in antisocial/psychopathic offenders • Cf to index offences, function among inpatients was more likely to include social status needs

42. Offender Service-Use Scale • Placement (safe/camera/segregation/normal cell) • Specialist staff (RAIT/IAT/additional staff) • Use of force (Low/Med/High) • Use of force type (physical/mechanical/chemical) • Access to programmes • Escorts (clinic/hospital/EHR/HR) • Internal charges • Additional to normal out of cell times

43. Obstacles • Resistance from correctional management • Concerns about loss of control/ ‘exposure’ • Suspicion about non-custodial staff • Lack of support of management plans • Resistance from base-grade staff • Poor record keeping • Suspicious about general data collection procedures • Failure to adhere to plans consistently

44. Obstacles • Staffing issues: • irregular staffing • ‘splitting’ between staff • Many staff have themselves been assaulted/targeted by offenders • Industrial issues: unions provide parameters for many plans • Lack of options for progression

45. Summary • Offenders with severe PD and challenging behaviours are often placed in high security, restrictive settings and limited access to services • These behaviours tend to be resistant to change and require intensive intervention • PBDU works collaboratively with centre-based staff using existing resources to develop effective behavioural interventions which enhance the good management of the centre